Introduction to the Care Management Manual
UCare developed this Care Management Manual as a means of disseminating instructions and guidance to care coordinators and case managers as they provide these services to our members in different UCare health plans.
Care coordination/case management supports UCare’s mission statement, which is “to improve the health of our members through innovative services and partnerships across communities.” Additionally, UCare is required through contracts with the Minnesota Department of Human Services (DHS) and by the Centers for Medicare & Medicaid Services (CMS) to provide care coordination and/or case management for specific UCare health plans.
UCare follows the requirements set forth by our regulators to set the requirements for case management/care coordination for UCare staff and delegated entities. UCare outlines these requirements on case management/care coordination requirement documents. UCare modifies these requirements from time to time, as regulatory requirements change, and notifies care coordinators and case managers of the changes in several ways:
UCare and/or delegated entities provide case management and care coordination for enrollees in the following UCare health plans:
Case management is a collaborative process. It involves assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs, through communication and available resources, to promote high-quality, cost-effective outcomes. The goals of case management are to:
UCare supports and follows the guidelines for the standards of practice from the Case Management Society of America (CMSA). These standards of performance include:
UCare and its delegated entities' case management practices must be consistent with relevant Minnesota Department of Human Services (DHS) contract provisions regarding care coordination/case management services.
Care coordination is the coordination of services for a member among different health and social service professionals and across settings of care. Care coordination can include case management as described above, or can consist of a more limited coordination role such as referral to a service.
UCare Health Plans
Minnesota Health Care Programs (MHCP)
MinnesotaCare– A state-subsidized program for people and families without access to affordable health care coverage, and living in UCare’s 78-county service area.
Prepaid Medical Assistance Program (PMAP) – A federally and state-funded program for people and families who meet income and other eligibility requirements, including living in UCare’s 55-county service area. This program provides medical services to Medical Assistance managed care enrollees.
Minnesota Senior Care Plus (MSC Plus) – A federally and state-funded program for people age 65 or older who meet income and other eligibility requirements, and live in UCare’s 55-county service area. This program provides medical services to Medical Assistance managed care enrollees.
UCare Connect – A plan designed to meet the unique needs of adults with certified physical disabilities, developmental disabilities, and/or mental illness. It is for people ages 18-64 who are eligible for Medical Assistance and who live in UCare’s 41-county service area.
UCare’s Minnesota Senior Health Options (MSHO) – A plan that combines the benefits of Medicare and Medicaid. It is for people ages 65 and older who are eligible for Medical Assistance and are enrolled in Medicare Parts A and B, and who live in UCare’s 57-county service area.
UCare Medicare Plans (formerly UCare for Seniors) (Medicare Advantage, HMO-POS) – An affordable Medicare plan available throughout Minnesota and in 26 western Wisconsin counties. Members can choose from three plan options: Value, Standard D, Value Plus, and Classic.
UCare Medicare Group Plans (formerly Group UCare for Seniors) – An affordable Medicare Advantage plan offered to the retirees of more than 60 employers. UCare Medicare Group Plans is available to Medicare-eligible retirees and their Medicare-eligible dependents.
CaringBridge is a way for members to stay connected with their support systems during a health challenge, and for their friends and family to plan practical support.
Minnesota Senior Care Plus
Rate Cells | MSHO and MSC Plus
MSHO and MSC+ health plans are paid based on rate cells. Assignment of rate cell categories is done by the State of Minnesota, based on information in Medicaid Management Information Systems (MMIS) at the time of capitation. The rate cell is determined on the day of capitation for the following month. Managed care capitation normally occurs six working days before the end of the month. An example is that the day of capitation was March 24, 2009, for the month of April.
MSHO and MSC+ rate cell changes have been automated since January 2006.
MSHO and MSC+ Responsibilities
Hospice for MSHO (Rate Cell Categories E and F)
The UCare Provider Manual is a reference guide for direct service providers of all types who serve UCare members. Updated regularly, its guidelines are part of the contract between UCare and its provider network. The manual lays out policies and procedures as well as tools and guidelines to assist providers in working with UCare and our members.
Utilization review is a formal evaluation of the medical necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities. Reviews are completed by a person or entity other than the attending health care professional to determine the medical necessity of the service or admission.
Utilization review also includes reviews conducted after the admission of the member. It includes situations where the member is unconscious or otherwise unable to provide advance notification. Utilization review may be conducted prior to service (pre-service), or concurrent or retrospective (post-service). UCare follows the standards set forth in Minnesota statue or provider contract as applicable.
Notification is required from providers for certain high-cost or high-utilization services. Services requiring notification are listed in the Authorization and Notification Requirements. The provider must inform UCare upon providing those services to a member. Prior authorization is not required for members to access participating providers for services not on the prior authorization list.
Delegation of Utilization Management occurs when UCare contracts with an external organization (“delegated entity”) to perform specific utilization management functions, such as utilization review for specified geographic populations, UCare plans, or services. The contract between UCare and the delegated entity is called a delegation agreement. This agreement is mutually agreed upon, and describes the delegated functions or activities, and the specific responsibilities, of both parties.
UR Communication Form
The UR Communication Form can be used for communicating PCA and Home Health Care Services requests and changes to UCare. The form can be used to request the start, extension, reduction, or termination of services. This form is not used to initiate medical services such as home health aide and skilled nursing visits. Those requests must come to UCare from the home care agency. It is appropriate to use this form to communicate requests to reduce or terminate home care services that are discovered to be duplicative, that cause the waiver budget cap to be exceeded, or that the member is refusing. Use the form to communicate authorization of extended home care services (extended PCA, extended HHA, extended Private Duty Nursing etc.)
UCare delegates utilization management and case management/care coordination to selected care systems, counties, and other agencies.
The clinical compliance team resides in UCare’s Corporate Compliance Department. The team’s primary function is to oversee the delegated utilization management and case management/care coordination activities performed by delegates of UCare to ensure that the delegates maintain compliance with regulatory and contractual obligations. UCare also provides clinical liaisons for care system and county delegates.
Delegation oversight has four main components.
Pre-delegation Assessment. UCare conducts a pre-delegation assessment prior to formal delegation, in order to assess the entity’s willingness and ability to perform the desired delegated functions.
Delegation Agreement. Once UCare determines that the delegate is willing and able to perform the functions appropriately, UCare enters into a delegation agreement with the delegate.
The agreement specifies the agreed-upon activities of both UCare and the delegate. Annual Oversight Audit. UCare conducts an annual oversight audit of all delegates. UCare uses audit tools designed to assess the performance of the delegate based on the delegation agreement and required regulations. System delegates performing utilization management are audited on an annual basis.
UCare makes an effort to inform delegates of the expectations for compliance prior to the annual audit. This is done by disseminating the content of the audit tool and audit process to delegates, as well as conducting compliance education for delegates.
Ongoing Oversight. UCare conducts ongoing oversight of all delegates throughout the year. This consists of ongoing communication with delegates, as well as review and follow-up related to the performance of all delegated activities by each delegate. The oversight is conducted through face-to-face meetings, e-mails, phone conversations, audit report reviews and follow-up, and ongoing compliance education for delegates.
Clinical Care System and County Liaisons
Disease management is a coordinated care approach focused on prevention, early identification, and intervention in the chronic disease process. Its goal is to provide cost-effective, holistic, and quality health care for a patient population identified as having a specific chronic illness or medical condition.
Disease management interventions and communications are targeted to patients to promote self-care efforts and treatment plans that will help them better manage their conditions. The goal is to improve the health of these individuals by working more directly with them and their physicians to improve health outcomes.
UCare Disease Management programs apply a multi-disciplinary, continuum-based approach to improve the health of members with a specific chronic illness or medical condition by:
State and federal requirements affect UCare’s Disease Management programs. The 2012 Department of Human Services (DHS) contract for Families and Children and the 2012 Special Needs Basic contract mandate a disease management program for asthma, diabetes, and heart disease. The Minnesota Senior Health Options (MSHO) contracts mandate disease management programs for diabetes and heart disease.
Currently, UCare’s disease management services are targeted to members with the following chronic illnesses or medical conditions:
These conditions (with the exception of asthma) have been combined into the Health Journeys program that utilizes health coaching across the co-morbid condition continuum. A Health Journeys booklet is given to members who opt into the program.
Members receive equipment, such as a wrist blood pressure cuff, bathroom scale, or educational materias) based on their conditions and goals. The primary care clinic and care coordinator/case manager receive a letter of member enrollment into the program.
UCare provides disease management services for its members either directly through UCare-administered programs or contracted disease management vendors. New disease management programs are approved by senior leadership following a review by
Clinical Services staff that, at a minimum, evaluates:
Disease management programs are evaluated annually using these criteria:
UCare’s Quality Improvement Advisory and Credentialing Committee (QIACC) provides input for individual programs.
Furthermore, UCare follows the Standards for Accreditation of Managed Care Organization established by the National Committee for Quality Assurance (NCQA). The program structure is described in UCare's Utilization Management Plan and implemented through Clinical Services policies and procedures.
UCare’s Quality Improvement activities include identifying and implementing a wide array of initiatives and projects that focus on improving the health of our members. In addition to working with our regulatory organizations, UCare collaborates with other health plans and partners with UCare providers on quality improvement projects to improve the health of our members.
UCare adopts and disseminates clinical practice guidelines to enhance member and clinical decision-making, improve health care outcomes, and meet state and federal regulatory requirements. These practices are found in the UCare Provider Manual.